Provider Demographics
NPI:1124089222
Name:ENNEN, RANDY M (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:M
Last Name:ENNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3312 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5052
Mailing Address - Country:US
Mailing Address - Phone:479-452-7800
Mailing Address - Fax:479-452-9486
Practice Address - Street 1:3312 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5052
Practice Address - Country:US
Practice Address - Phone:479-452-7800
Practice Address - Fax:479-452-9486
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR114450001Medicaid
OK100177380AMedicaid
C68154Medicare UPIN
AR114450001Medicaid
51347Medicare PIN